1 / 32

Kidney Committee

This slideshow provides an analysis of the first 18 months of the implementation of the new Kidney Allocation System (KAS), including changes in transplant volume, regional distribution, pediatric transplants, recipient outcomes, and kidney utilization. It also highlights the impact of KAS on highly sensitized and high dialysis time patients, as well as the challenges of the KDPI mapping table.

kress
Download Presentation

Kidney Committee

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Kidney Committee Fall 2016

  2. Recent Public Comment Proposals – Board approved

  3. Recent Public Comment Proposals – Board approved

  4. The New Kidney Allocation System (KAS): The First 18 Months Darren Stewart, MS John Beck, MSME Anna Kucheryavaya, MS UNOS Research Department Slideset updated 08/12/2016

  5. Topics • Background • Transplant volume • Regional distribution of transplants • Pediatric transplants • “Bolus” effects • CPRA 99-100 recipients • Recipients with 10+ years on dialysis • Kidney utilization • Recipient outcomes • KDPI mapping table error (April 20 – May 19, 2016)

  6. Background • KAS implemented Dec 4, 2014 • Key goals: • Make better use of available kidneys • Increase transplant opportunities for difficult-to-match patients (increased equity) • Increase fairness by awarding waiting time points based on dialysis start date • Have minimal impact on most candidates

  7. Analysis periods • Pre-KAS: Dec 4, 2013 – Dec 3, 2014 (12 months) • Post-KAS: Dec 4, 2014 – May 31, 2016 (~18 months) Some slides include a longer post-KAS evaluation (e.g., 19 or 20 months, as indicated)

  8. Solitary deceased donor kidney transplants under KAS Pre vs. post-KAS trends • Transplant volume increased 6.9%, from 896.0 to 955.7 per month. Over time (per 30 days) Overall (per 30 days) June 2016 KAS implementation 1 year 18 months

  9. Regional distribution of kidney transplants • Most changes in % of transplants by Region were very small. • Largest relative changes: Region 9↑; Region 6↓.

  10. Trends in pediatric transplants Percent of DD Kidney Transplants to Pediatrics (results through July 31, 2016) (Dec 3, 2014 – May 2015) (Dec 2015 – July 2016) (Jun 2015 – Nov 2015) (Dec 4, 2013 – Dec 3, 2014) • Pediatrics represent 0.9% of the kidney WL and account for about 4% of transplants. • Small Post-KAS increase for age 6-10, decreases for age 0-5, 11-17, and overall.

  11. Geographic distribution of pediatric kidney transplants Percent of Pediatric DD Kidney Transplants by Region (through July 31, 2016) (Dec 3, 2014 – July 31, 2016) • Most regions had higher or similar percent of pediatric transplants post-KAS. • However, the % of pediatric transplants occurring in region 5 dropped from 21.4% to 15.2%. 26.3% of pediatric candidates are registered in Region 5.

  12. CPRA 99-100% recipient “bolus effect” • Transplants to CPRA 99-100% patients rose sharply after KAS but have tapered to around 10%. (June 2016) Transplant date

  13. High dialysis time recipient “bolus effect” • After KAS, the % of transplants to recipients with 10+ years of dialysis rose sharply to nearly 19% but has tapered to about 7%. Transplant date Based on CMS Crownweb dialysis dataset as of 3/31/2016

  14. Kidney Utilization by KDPI • “Discard rate” = percentage of kidneys recovered for transplant but not transplanted. Rate increased, fell, then rose again post-KAS. (mos. 13-18) Kidney discard rate

  15. Kidney Utilization by KDPI • Overall, the discard rate rose from 18.5% to 19.8% (p=0.001). The increase was most evident for KDPI 86-100% kidneys. Kidney discard rate

  16. Delayed graft function (DGF) rates (1 year pre vs. 18-months post KAS)DGF = dialysis within first week • The percentage of recipients requiring dialysis within the first week after transplant increased from 24.3% pre-KAS to 29.5% after KAS. • Increase driven by more high dialysis time recipients and other factors.

  17. DGF Trend (transplants through May, 2016) • Slight decline in DGF rate post-KAS(p=0.03), likely due to diminishing bolus effects (e.g., fewer high dialysis time recipients). % of transplants requiring dialysis within 1 week

  18. Six Month Survival • Six month graft survival rate over 95%. Patient survival over 97% but slightly lower than pre-KAS (p<0.05). Log-rank p-value=0.12 Log-rank p-value=0.04 (28%) (40%) % Graft survival at 6 months (60% of accepts) % Patient survival at 6 months Transplant date Transplant date

  19. Highlights: First 18 months of KAS • Many very highly sensitized and high dialysis time patients have been transplanted under KAS • Transplants to these groups have tapered over 18 months • Deceased donor transplant volume has increased 7% • However, utilization of recovered kidneys has not improved • Largest impact on pediatric transplants was observed in Region 5. • DGF has increased but is slowly trending downward • Post-KAS, 6-month graft (95.3%) and recipient (97.6%) survival are excellent, though slightly lower than pre-KAS.

  20. Additional information • For more detailed analyses of KAS’s impact after 1 year, other resources are available: • https://www.transplantpro.org/wp-content/uploads/sites/3/KAS_12month_analysis.pdf • Stewart, D. E., Kucheryavaya, A. Y., Klassen, D. K., Turgeon, N. A., Formica, R. N., & Aeder, M. I. (2016). Changes in Deceased Donor Kidney Transplantation One Year After KAS Implementation. American Journal of Transplantation, 16(6), 1834-1847.)

  21. Incorrect KDPI Mapping Table

  22. Background • KDRI was incorrectly mapped to KDPI between April 20, 2016 – May 19, 2016 • Start of problem: 2016-04-20 07:34:13.020 • Problem fixed: 2016-05-19 11:31:34.640 • Source of problem: incorrect “mapping table” uploaded for converting KDRI to KDPI • Impact: • All KDPI values* displayed in DonorNet and used for allocation were higher than they should have been. • On average, the displayed KDPI was 17 points higher than the correct value. The maximum deviation was 21 points. * Except KDPI values of 100%, since KDPI cannot be higher than 100%.

  23. Shift in KDPI values due to incorrect mapping for 930 affected transplants 35-85 0-20 21-34 86-100 Actual KDPI’s Mean=46.4 Incorrectly mapped KDPI’s Mean=63.7 KDPI Distribution of KDPI used for allocation shifted to higher values.

  24. KAS sequences dependent upon KDPI

  25. Differences in allocation sequence due to incorrect KDPI D A B C 149 fewer transplants were allocated per sequence A (KDPI 0-20). 121 more transplants were allocated per sequence D (KDPI 86-100).

  26. Impact of incorrect KDPI mappingEPTS 0-20% recipients Transplants to EPTS 0-20% adults dropped and rebounded after the system was fixed.

  27. Impact of incorrect KDPI mappingEPTS 21-100% recipients Transplants to EPTS 21-100% adults increased then returned to previous levels after the fix.

  28. Fixing the problem • The correct table was uploaded on May 19th, 2016 • Tested by IT department and validated by Research department • Working as expected since May 19th, 2016 • New processes put in place to prevent future problems of this nature • All programs that performed a transplant during this period were informed of the correct (lower) KDPI value for each recipient. 28

  29. Impact on distribution of deceased donor kidney transplants% of transplants received by groups of recipients The distribution of transplants shifted toward older recipients during this one month period but subsequently returned to previous levels. 29

  30. Impact of KDPI mapping error: summary of findings • Deceased donor kidney transplant volume remained on par with post-KAS average and was 9% above the pre-KAS average. • The kidney discard rate was slightly higher (22.9%, vs. 19.7% post-KAS average) but not outside normal, observed monthly variation • For this one month period, the distribution of transplants resembled pre-KAS with respect to longevity matching and recipient ages. • Pediatric transplants declined slightly but rebounded sharply post-fix. • Transplants to highly sensitized and African American patients were unaffected.

  31. UNOS Research Department Data Quality Team Catherine Monstello, RRT, CPHQ John Beck, MSME Sherri Williams Brooke Chenault, CCRA Jessie Maker, MS Tammy Snead Tenisha Atobrah Penny Brock Sharon Graves Clay McDonald Jo Smith Data Scientists Harris McGehee Data Analytics Team Sarah Taranto Tim Baker Jude Maghirang, MS Yulin Cheng Eric Beeson Alex Garza Heather Neil Denise Tripp Ann Harper, MPH Jaime Williamson Wes Rosson Alice Toll Scientists and Analysts Leah Edwards, PhD Erick Edwards, PhD Wida Cherikh, PhD Bob Carrico, PhD John Rosendale, MS Darren Stewart, MS Jennifer Wainright, PhD Marissa Clark-Quimby, MS Amber Wilk, PhD Anna Kucheryavaya, MS Mike Curry, MS Read Urban, MPH Victoria Garcia, MPH Amanda Robinson, MS Leadership Ryan Ehrensberger, PhD, FACHE David Klassen, MD Cherri Taylor

  32. Questions? Mark Aeder, M.D. Committee Chair mark.aeder@uhhospitals.org Melinda Woodbury Committee Liaison melinda.woodbury@unos.org

More Related